We all love to watch experts at work, they make what they do look so effortless, and whilst it is certainly possible to learn from watching these people in action it is even better to have them explain exactly what, why and how they do what they do. Whether it is Queen explaining how Bohemian Rhapsody came to life, a masterclass from Michael Caine on how to act or Shane Warne explaining how he bowls leg spin that personal tuition offers us an insight in to the effort they have put in to get where they are and a chance to learn from their experience.
Medicine is little different and for those of us who might be considered to have reached ‘expert’ level we are used to being watched by junior colleagues as they learn how to get better…but better at what? Traditionally we learn most of our clinical medicine by watching experts, rows of medical students sat in the outpatient clinic or juniors following the consultant on their ward round or theatre list. Thankfully we’ve (mostly) moved on from see one, do one, teach one but we are still heavily reliant upon ‘see’ when it comes to learning and this is a particular problem because the real core of what we do can’t be seen. What marks us out as seniors isn’t necessarily what we can do, it is more about how we think… and that can’t be seen. All our juniors see are the expert output from our thought processes; the unusual diagnosis, the correct incision, the revealing question but they do not see how we got there, the processing of information, knowledge and experience that led to that output, the very nature of an expert.
I believe this is one of the hardest things for junior staff to learn, how to think like a senior, like an expert. They can gain knowledge, learn practical skills and even develop critical thinking techniques but expertise, the ability to apply each of these appropriately, takes time, needs experience. So, is there a way we can make our expert thinking more visible, a way to help them understand our actions?
Here are a few ideas on how we could.
Thinking Out Loud
When a junior presents a case to us, rather than letting them present the whole case (history, examination, investigations, management plan etc) and then commenting about it at the end, pause throughout the presentation to explain what we are thinking. What cues did we pick up from the past history? Did their occupation alter what we thought? Why were we surprised by the blood pressure or the chest findings? In this way the junior gets to ‘see’ what we are thinking, how that might vary through the presentation and realises the level they need to get to in order to become an expert. Interrupting like this might be a bit confusing and potentially even intimidating for the junior, if we don’t warn them first. However, in my experience, if we explain what we are trying to do, they get used to it and ultimately find it very useful, particularly when they feel confident to challenge what we are thinking!
Thinking About What is Key
A junior presents a case, including their management plan, and waits for approval and/or correction. Again, rather than commenting on the case as a whole, instead alter some of the variables that we feel are key and see how that changes their thoughts. What if they lived with a carer? What if their systolic blood pressure was 85 rather than 95? How about we say the ECG shows atrial fibrillation instead of sinus rhythm? Share why we have chosen those particular variables and how they would have to change to alter our position on the case. Again, by discussing the case in this way, the junior gets to understand the need to process the multiple variables involved in clinical care and learns how someone of experience thinks. It also helps us avoid falling in to an outcome bias, judging a junior by their final decision, rather than their diagnostic reasoning. A correct diagnosis or management plan could be the result of flawed thinking or even a lucky guess. Far better for us to understand HOW they got to their conclusion, what reasoning occurred and judgements were made, and correct any errors there rather than examining the end product.
In the ED, an OP clinic or the acute ward, see a patient with a junior and gather the information together. At regular intervals stop and explain what we are thinking, what history or examination findings we are starting to look for and diagnoses we are considering specifically. Perhaps most helpfully, be honest and explain what happens if we don’t find what we are expecting and have to reconsider the path our thoughts have taken us down. In doing this our colleague gets to see how we think in real time, how nimble our thought processes have to be, how we move between pattern recognition and critical evaluation on our way through a consultation…the mark of an expert.
Clearly this could be quite an experience for the patient, having all your thinking laid bare to them, so we need to make sure that we explain what is going to happen prior to doing this and quite probably debrief them afterwards should certain frightening diagnoses be raised as possibilities, even if they are ultimately rejected.
Whilst each of these is suggested as a real clinical encounter, they could be adapted to a virtual or simulated patient or even a case presentation. To get a feel how that might work you should listen to one of the podcasts from IM Reasoning who do this regularly in their ‘Stump the Chumps’ episodes. Listening to two experts discuss a presentation as it unfolds through history, examination and investigations is an enlightening experience.
Whatever way we choose to do it, letting junior staff in on our thought processes is not just an incredibly valuable educational experience for them, it has other benefits too. It is good clinically because expert as we are, none of us are perfect, so it is not unusual for us to learn something in these exchanges with our juniors, particularly those studying for exams! This is great for us as we gain both knowledge and humility but it is also better for patients because they are more likely to get the excellent care they need. There are also professional, behavioural benefits to be had. These techniques bring a sense of collaboration to the case as we work the problem together, modelling a mature professional relationship, flattening the hierarchy appropriately and encouraging our colleagues to be collaborative, open clinicians themselves.